JADA Continuing Education
Oral cancer knowledge, risk factors and characteristics of subjects in a large oral cancer screening program
GUSTAVO D. CRUZ, D.M.D., M.P.H.,
RACQUEL Z. LE GEROS, Ph.D.,
JAMIE S. OSTROFF, Ph.D.,
JENNIFER L. HAY, Ph.D.,
HERBERT KENIGSBERG, D.D.S. and
D. MERCEDES FRANKLIN, D.M.D., M.P.H.
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ABSTRACT
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Background. Screening people who are at high risk of developing oral cancers is a promising tool for decreasing morbidity and mortality attributable to this cancer.
Methods. A consortium led by the New York University College of Dentistry conducted a three-day oral cancer screening during June 1999. As part of the screening intake, the authors conducted a survey to assess the sociodemographic characteristics, level of knowledge of risk factors and predictors of oral cancer awareness among the subjects. The authors performed bivariate and multivariate analyses using two indicators of oral cancer awareness as dependent variables.
Results. The 803 subjects were racially and ethnically diverse, 66 percent were 40 years of age or older, 43 percent had a history of smoking, and 9 percent were likely to have had a history of alcohol abuse. Race/ethnicity, education level and knowledge of risk factors for oral cancer were predictors of awareness of an oral cancer examination, whereas only knowledge and possible history of alcohol abuse were predictors of having a history of examinations.
Conclusions. This screening program attracted a diverse sample of people at high risk of developing oral cancer due to smoking and likely history of alcohol abuse. Consistent with other national and international studies, the authors found a lack of knowledge of the risk factors associated with oral cancer and a low rate of histories of oral cancer examinations among the subjects.
Clinical Implications. Oral cancer screening programs represent potential opportunities not only for early detection of oral cancer but to raise awareness and educate the public about the disease.
Oral and pharyngeal cancers account for 3 percent of all diagnosed malignancies in the United States.1 An estimated 32,000 new cases are diagnosed annually. In addition, more than 8,000 deaths are attributable to oral cancer each year. Major risk factors for oral cancer include alcohol and tobacco use, as well as sun exposure for lip cancer; tobacco use is responsible for 90 percent of these cancers2; and heavy smokers who are older than 40 years of age and use alcohol are at the highest risk.3 Epidemiologic findings highlight the disproportionate incidence, morbidity and mortality associated with oral and pharyngeal cancers in minority populations, particularly African-American males.4
Oral cancer screenings can target people at high risk of developing oral cancer who then potentially can be educated about the risk factors and early signs of oral cancer.
Patients diagnosed with localized tumors have a five-year survival rate of 80 percent, whereas patients diagnosed with regional metastasis have a five-year survival rate of 40 percent.5 Unfortunately, more than one-half of all oral and pharyngeal cancers in the United States are diagnosed at late stages. Although oral cancers are curable when diagnosed and treated early, the overall U.S. five-year survival rate for oral cancers is only 52 percent.4 Similar to observations for other types of cancer, racial and ethnic minorities typically are diagnosed with oral cancer at later stages.6
Screening high-risk people is a promising goal for decreasing the morbidity and mortality attributable to oral cancers.7,8 Although no studies have demonstrated the efficacy of population-based oral cancer screenings, the American Cancer Society recommends annual oral cancer examinations for all people 40 years of age or older.9 The U.S. Preventive Services Task Force recommends a careful oral cancer examination for all people who use tobacco or alcohol.10 Furthermore, patients who have oral and head and neck cancer have reported frequent visits to oral and medical health care providers before their diagnoses.11 Those health care visits represent potential opportunities for early detection and education.
Oral cancer screenings may provide an excellent opportunity for raising public awareness and providing patient education and counseling regarding behavioral risk factors and how to reduce them.
Given that 85 percent of head and neck cancers are readily visible,12 oral cancer screenings are an inexpensive, safe and noninvasive method of detection. Oral cancer screenings also may provide an excellent opportunity for raising public awareness and providing patient education and counseling regarding behavioral risk factors and how to reduce them. Since people older than 40 years of age who use alcohol and tobacco are at the highest risk of developing oral cancers, screening this high-risk cohort is of paramount public health importance. Furthermore, oral cancer has been found to meet most of Wilson and Jungner’s13 criteria for a disease suitable for screening.14
Unfortunately, despite the low cost and likely public health benefits—particularly for people at high risk—primary care physicians and dentists have not routinely offered oral cancer screenings.15,16 Several population-based surveys have found that the oral cancer screening is an under-used service in this country.17,18 For example, based on responses to the 1992 National Health Interview Survey, Horowitz and Nourjah18 found that only 15 percent of the respondents reported ever having had an oral cancer examination. Community-based free oral cancer screening programs have been underused by people who are at high risk owing to their history of alcohol use, tobacco use or both.19,20
Given the lack of public awareness of the signs, symptoms and risk factors associated with oral cancer, which has been hypothesized to be a potent barrier for the early detection of oral cancers,18,21 we conducted a brief, prescreening survey at a free three-day oral cancer screening conducted in New York City to assess the risk factors and health education needs of the screening subjects.
Specifically, we conducted this study to determine subjects’ knowledge of oral cancer risk factors, to assess their awareness and history of oral cancer examinations, and to identify the predictors associated with oral cancer awareness, history of examinations and knowledge of risk factors.
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METHODS
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A consortium of four dental schools in the New York state and New Jersey area, as well as the Office of Oral Health, Programs and Policy, or OOHPP, for New York City, led by the New York University College of Dentistry, or NYUCD, conducted a three-day oral cancer screening during June 1999 at several sites in the New York state and New Jersey area. As part of the screening, the Minority Oral Health Research Center at NYUCD and OOHPP conducted a brief pre-screening survey among the subjects in the New York City metropolitan area. We obtained institutional review board approval from New York University before the study began.
We trained interviewers in a two-hour session, and they administered the instrument. Only five of the screening participants refused to participate in the prescreening survey. The survey instrument comprised 21 items that assessed the subjects’ awareness of oral cancer, knowledge of risk factors for oral cancer, knowledge of other conditions associated with alcohol and tobacco use, and perceived risk for oral cancer. We also collected sociodemographic information such as age, sex, race/ethnicity, educational level, and history and current use of alcohol and tobacco. We assessed oral cancer awareness by asking the following questions: "Have you ever heard of oral (mouth or lip) cancer?" and "Have you ever heard of an oral cancer exam?" We assessed subjects’ histories of oral cancer examinations by asking, "Have you ever had an oral cancer exam?" Response categories for all three questions were "Yes," "No" and "Don’t Know/Not Sure."22 If the subjects reported a lack of knowledge about oral cancer examinations, we described the examination to them.
To assess knowledge of risk factors for oral cancer, we asked subjects to indicate, using a four-point scale (1 = definitely does not increase risk, 2 = probably does not increase risk, 3 = probably increases risk, 4 = definitely increases risk), whether they believed that the following factors contribute to a person’s chances of getting oral (mouth or lip) cancer: excessive exposure to sunlight; eating hot, spicy foods; regular consumption of alcohol; tobacco use; and frequently biting the cheek or lip.22 By summing the number of correct answers to the five items, we derived a total knowledge score. We defined as correct "definitely increases" answers for all factors except for the second and last, which were correctly answered as "definitely does not increase." Possible scores ranged from 0 to 5. For analyses purposes, we collapsed the results into four categories: 0, 1, 2 and 3 and above. The survey also included questions about lifetime and current tobacco use, current level of alcohol use and readiness to quit smoking.23 We used the CAGE (Cutting down, Annoyance by criticism, Guilty feeling and Eye-openers) questionnaire to assess the likelihood of lifetime alcohol abuse.24 Questions comprising the CAGE questionnaire include "Have you ever felt you ought to cut down on your drinking?", "Have other people annoyed you by criticizing your drinking?", "Have you ever felt bad or guilty about your drinking?" and "Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?" Possible responses were "Yes" or "No." We constructed a total score (CAGE score) by adding all of the "Yes" responses. Subjects who had a score of 2 or greater were deemed to have had a likelihood of a history of alcohol abuse. This screening instrument has been shown to have a sensitivity of 75 percent and specificity of 96 percent in identifying history of alcohol dependence.25
Analysis showed that education level, race/ethnicity and oral cancer risk factor knowledge score were independent predictors of the awareness of an oral cancer examination.
We carried out bivariate analysis of the association between each of the independent variables and the subjects’ having heard about an oral cancer examination and having a history of oral cancer examinations using 
2 tests. A P value of .05 or less was deemed to be significant. We analyzed all significant variables at the bivariate level in a multivariate context using logistic regression models. The Wald statistic at the .05 level was used to determine which variables would be included in the logistic regression models, and we calculated odds ratios and 95 percent confidence intervals from the regression coefficients. We used a specialized software program (SAS/STAT, Release 6.12, SAS Institute, Cary, N.C.) for all of the statistical analyses.
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RESULTS
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The ages of the 803 subjects ranged from 16 to 100 years. The mean age was 49.46 (standard deviation, or SD, = 18.26), and the median age was 47 years. The majority of the subjects (66 percent, n = 533) were 40 years of age or older, female (63 percent, n = 507) and racially/ethnically diverse. Thirty-six percent (n = 288) identified themselves as white, 37 percent (n = 296) as black, 18 percent (n = 145) as Hispanic and 7 percent (n = 60) as Asian or other racial/ethnic background. Fifty-four percent (n = 437) had at least a high-school education, and 43 percent (n = 347) reported having smoked at least 100 cigarettes in their lifetimes; of these, 48 percent (n = 165) were current smokers. Furthermore, 9 percent (n = 73) of all the subjects were likely to have had a history of alcohol abuse (Table 1
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The total knowledge of risk factor scores varied; 20 percent of the subjects had a total score of 0, 36 percent had a total score of 1, 27 percent a total score of 2, and 17 percent a total score of 3 or higher. Most of the subjects (66 percent; n = 529) had heard about oral cancer; however, only 39 percent (n = 311) reported having heard of an oral cancer examination, and only 12 percent (n = 99) reported ever having had an oral cancer examination (Table 2).
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TABLE 2 KNOWLEDGE OF RISK FACTORS SCORES, AWARENESS OF ORAL CANCER AND EXISTENCE OF A SCREENING EXAMINATION, AND HISTORY OF ORAL CANCER EXAMINATIONS.
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Knowledge concerning risk factors varied greatly; 76 percent of the subjects (n = 608) knew that tobacco is a risk factor for oral cancer, whereas only 25 percent (n = 204) knew that alcohol was. Knowledge of excessive sunlight as a risk factor for lip cancer was reported by 25 percent (n = 204). Furthermore, only 24 percent (n = 191) knew that frequent cheek or lip biting was not a risk factor for oral cancer, and 40 percent (n = 320) knew that eating hot, spicy foods was not a risk factor. When the interviewers asked the subjects if they thought that heavy alcohol use increases a person’s chance of developing oral cancer, only 33 percent (n = 267) said they thought it definitely increases the risk. In contrast, 75 percent (n = 603) knew that tobacco use increases a person’s chance of developing oral cancer.
We found significant differences in the subjects’ awareness of the existence of an oral cancer examination at the bivariate level between educational levels, racial/ethnic groups, those who reported having smoked at least 100 cigarettes in their lifetimes and those who had higher risk factor knowledge scores (Table 3). In addition, we found significant differences among racial/ethnic groups, educational levels, possible history of alcohol abuse (CAGE scores), oral cancer risk factor knowledge scores and history of oral cancer examinations.
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TABLE 3 BIVARIATE ANALYSIS FOR AWARENESS OF EXISTENCE OF AN ORAL CANCER EXAMINATION AND HISTORY OF ORAL CANCER EXAMINATIONS.
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Multivariate logistic regression analysis showed that education level, race/ethnicity and oral cancer risk factor knowledge score were independent predictors of the awareness of an oral cancer examination (Table 4). White and black subjects were more likely to be aware of the existence of an oral cancer examination than were Hispanic subjects. Those with a higher education and higher knowledge score also were more likely to have had an oral cancer examination than were those at a lower education level and with lower knowledge scores.
Only knowledge of risk factor knowledge score and CAGE score retained significance on multivariate analysis for having a history of oral cancer examinations (Table 5). Subjects who had the highest knowledge scores were 3.95 times more likely than those who had the lowest knowledge scores to have had a history of oral cancer examinations. Those with higher CAGE scores (likely to have had a history of alcohol abuse) were 26 percent less likely to have had a history of oral cancer examinations than were those with lower scores. Furthermore, tobacco use was not an independent predictor of either awareness of an oral cancer examination or history of oral cancer examinations.
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DISCUSSION
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Although studies have yet to demonstrate the effectiveness of cancer screenings, such screenings are considered to be a promising tool for decreasing the morbidity and mortality attributable to oral cancers.7,8 Nevertheless, we have found evidence of only a couple similar large-scale screening programs in the United States.26,27
Our screening program was successful in attracting a diverse sample of people at high risk of developing oral cancer due to smoking, who likely had a history of alcohol abuse and were 40 years of age or older (66 percent)—the age for annual oral cancer examinations as recommended by the American Cancer Society.9 Some of the factors that contributed to this program’s success in attracting a large number of subjects who were at high risk of developing oral cancer due to tobacco and alcohol use included the following:
- – extensive publicity surrounding the event that included announcements in several newspapers, public service announcements on two local television stations and a live broadcast from the NYUCD screening site;
- – conducting the screening free of charge in several community-based health clinics, as well as at the on-site NYUCD clinics;
- – enlisting the support of a well-known black celebrity to publicize the event in televised public service announcements.
The large number of black subjects who participated in this program is noteworthy because of the need for oral cancer prevention and early detection promotion programs in this population, given existing racial disparities in oral cancer incidence, morbidity and mortality. The racial disparities in survival from oral cancer between blacks and whites have been attributed to a higher proportion of diagnoses of less-advanced cancers among whites than blacks.28 It also has been suggested that some of the reasons for the racial difference in diagnosis stage were lack of participation of blacks in screening activities, failure to recognize cancer symptoms and asymptomatic detections.6,29 In this study, we found significant differences in both the awareness of the existence of an oral cancer examination and having a history of oral cancer examinations among the racial/ethnic groups at the bivariate level. On multivariate analyses, race/ethnicity was a strong predictor of the awareness of the existence of an examination.
Consistent with other national and international studies, we found there was a lack of knowledge of the risk factors associated with oral cancer, with the exception of tobacco use. Furthermore, there was a lack of awareness of the existence of an oral cancer examination. It follows that the study’s subjects also had low histories of having oral cancer examinations. Even though several sociodemographic factors have been identified as determinants of compliance with cancer screenings, the most important barrier seems to be a lack of awareness about the test.30
In 1996, the National Strategic Planning Conference for the Prevention and Control of Oral and Pharyngeal Cancer recommended that members of the public be informed that an examination for oral cancer exists and that they should request one routinely from a variety of health care providers.31 There is widespread agreement that there is a need for broad dissemination of this information, as well as for educational programs on the risk factors and early signs and symptoms of oral cancer.17,21,22 Our findings underscore the need for and importance of these educational efforts, as knowledge of oral cancer risk factors was the only common predictor of the study subjects’ awareness of an oral cancer examination and having a history of oral cancer examinations. Tobacco cessation counseling, as well as education about alcohol abuse as a risk factor for oral cancer are especially important. In this study, subjects who had a higher CAGE score (those likely to have a history of alcohol abuse) were less likely to have had a history of oral cancer examinations than were those who had lower CAGE scores.
Although the results of this study are limited by the possibility of recall bias, the reported knowledge and oral cancer examination awareness deficits are all the more striking, as the subjects may represent the upper limits of the population estimates for oral cancer knowledge since they self-selected to seek screening for oral cancer.
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CONCLUSIONS
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This study suggests that oral cancer screenings can target and attract people at high risk of developing oral cancer who then potentially can be educated about the risk factors and early signs of oral cancer. The dissemination of information about oral cancer and awareness of the disease, especially among those who have risk factors, may lead to a reduction of risk factors associated with the disease, as well as early detection and reduction in the disparities in oral cancer incidence and survival rates in this country.
Our study results also reinforce the notion that the public, even those interested in participating in cancer screenings, are not appropriately aware of the risk factors for oral cancer, the existence of examinations and the importance of early detection.
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Dr. Cruz is an assistant professor and the director of public health, New York University College of Dentistry, Department of Epidemiology and Health Promotion, 324 East 24th Street, Room 806, New York, N.Y. 10010, e-mail "gustavo.cruz{at}nyu.edu". Address reprint requests to Dr. Cruz.
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Dr. Le Geros is the director, Minority Oral Health Center, and a professor, Department of Biomaterials and Biomimetics, New York University College of Dentistry, New York.
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Dr. Ostroff is an assistant attending psychologist, Memorial Sloan-Kettering Cancer Center, Department of Psychiatry and Behavioral Sciences, New York.
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Dr. Hay is a clinical assistant psychologist, Memorial Sloan-Kettering Cancer Center, Department of Psychiatry and Behavioral Sciences, New York.
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Dr. Kenigsberg is the director, Clinical Affairs and Disease Prevention, Office of Oral Health, Programs and Policy for New York City, New York Health and Hospitals Corporation, New York.
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Dr. Franklin is the director, Medical Affairs, Office of Oral Health, Programs and Policy for New York City, New York Health and Hospitals Corporation, New York.
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FOOTNOTES
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This study was partially supported by National Institutes of Dental and Craniofacial research grant DE 10593.
The authors thank the Minority Oral Health Research Center at New York University College of Dentistry and the Office of Oral Health, Programs and Policy interviewers for their diligence in collecting the data for this study. They also thank Farhanah Khan for her invaluable help in the preparation of the manuscript, Dr. Alice M. Horowitz for her support of this project, and the Oral Cancer Consortium for organizing the event.
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REFERENCES
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- American Cancer Society. Cancer facts and figures. Atlanta: American Cancer Society; 1999.
- Peto R, Lopez A, Boreham J, Thun M, Heath C. Health effects of tobacco use: global estimates and projections. In: Slama K, ed. Tobacco and health: Proceedings of the Ninth World Congress on Tobacco and Health, Paris, Oct. 10–14, 1994. New York: Plenum Press; 1995.
- Vokes EE, Weichselbaum RR, Lippman SM, Hong WK. Head and neck cancer. N Engl J Med 1993;328(3):184–94.[Free Full Text]
- Swango PA. Cancers of the oral cavity and pharynx in the United States: an epidemiologic overview. J Public Health Dent 1996;56(6): 309–18.[Medline]
- Ries LA, Kosray CL, Hankey BF, Miller BA, Clegg L, Edwards BK, eds. SEER cancer statistics review, 1973–1996. Bethesda, Md.: National Cancer Institute; 1999.
- Arbes SJ, Slade GD. Racial differences in stage at diagnosis of screenable oral cancers in North Carolina. J Public Health Dent 1996;56(6):352–4.[Medline]
- Mashberg A, Samit A. Early diagnosis of asymptomatic oral and oropharyngeal squamous cancers. CA Cancer J Clin 1995;45:328–51.[Abstract/Free Full Text]
- Horowitz AM, Goodman HS, Yellowitz JA, Nourjah PA. The need for health promotion in oral cancer prevention and early detection. J Public Health Dent 1996;56(6):319–30.[Medline]
- Update January 1992: the American Cancer Society guidelines for cancer-related checkup. CA Cancer J Clin 1992;42(1):44–5.[Medline]
- DiGuiseppe C, Atkins D. Guide to clinical preventive services: Report of the U.S. Preventive Services Task Force. 2nd ed. Baltimore: Williams & Wilkins; 1996.
- Prout MN, Heeren TC, Barber CE, et al. Use of health services before diagnosis of head and neck cancer among Boston residents. Am J Prev Med 1990;6(2):77–83.[Medline]
- Barry P, Katz PR. On cancer screening in the elderly. J Am Geriatr Soc 1989;37:913–4.[Medline]
- Wilson JM, Jungner G. Principles and practice of screening for disease. Geneva: World Health Organization; 1968.
- Speight PM, Downer MC, Zarzewska J, eds. Screening for oral cancer and precancer: report of a UK working group. Community Dent Health 1993;10(supplement 1):1–89.[Medline]
- Goodman HS, Yellowitz JA, Horowitz AM. Oral cancer prevention: the role of family practitioners. Arch Fam Med 1995;4:628–36.[Medline]
- Martin LM, Bouquot JE, Wingo PA, Heath CW Jr. Cancer prevention in the dental practice: oral cancer screening and tobacco cessation advice. J Public Health Dent 1996;56(6):336–40.[Medline]
- Horowitz AM, Moon HS, Goodman HS, Yellowitz JA. Maryland adults’ knowledge of oral cancer and having oral cancer examinations. J Public Health Dent 1998;58(4):281–7.[Medline]
- Horowitz AM, Nourjah PA. Factors associated with having oral cancer examinations among US adults 40 years of age or older. J Public Health Dent 1996;56(6):331–5.[Medline]
- Clayman GL, Chamberlain RM, Lee JJ, Lippman SM, Hong WK. Screening at a health fair to identify subjects for an oral leukoplakia chemoprevention trial. J Cancer Educ 1995;10(2):88–90.[Medline]
- Ostroff JS, Hay JL, Schantz SP, Maher MM. A survey of smoking status and cancer risk perceptions among participants attending a hospital-based head and neck screening program. Psychol Health 2000;14:979–90.
- Warnakulasuriya KA, Harris CK, Scarrott DM, et al. An alarming lack of public awareness towards oral cancer. Br Dent J 1999;187:319–22.[Medline]
- Horowitz AM, Nourjah P, Gift HC. U.S. adult knowledge of risk factors and signs of oral cancers: 1990. JADA 1995;126:39–45.
- Prochaska JO, DiClemente CC, Noircross JC. In search of how people change: applications of addictive behavior. Am Psychol 1983;47:1102–14.
- Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA 1984;252:1905–7.[Abstract]
- Bush B, Shaw S, Cleary P, Delbanco TL, Aronson MD. Screening for alcohol abuse using the CAGE questionnaire. Am J Med 1987;82:231–5.[Medline]
- Prout MN, Sidari JN, Witzburg RA, Grillone GA, Vaughan CW. Head and neck cancer screening among 4,611 tobacco users older than 40 years. Otolaryngol Head Neck Surg 1997;116:201–8.[Medline]
- McGuire M, Lydiatt W, Trambert R, Shaha A, Schantz S. Head and neck screening day for the community. Ann N Y Acad Sci 1995;768:286–8.[Medline]
- Boring CC, Squires TS, Heath CW Jr. Cancer statistics for African Americans. CA Cancer J Clin 1992;42(1):7–17.[Abstract]
- Howard J, Hankey BF, Greenberg RS, et al. A collaborative study of differences in the survival rates of black patients and white patients with cancer. Cancer 1992;69:2349–60.[Medline]
- Meissner HI, Potosky AL, Convissor R. How sources of health information relate to knowledge and use of cancer screening exams. J Community Health 1992;17(3):153–65.[Medline]
- Preventing and controlling oral and pharyngeal cancer: recommendations from a National Strategic Planning Conference. MMWR Recomm Rep 1998;47(RR-14):1–12.[Medline]
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ABSTRACT
METHODS
